title: Bridging intravenous-intra-arterial rescue strategy increases recanalization and the likelihood of a good outcome in nonresponder intravenous tissue plasminogen activator-treated patients: a case-control study.
abstract: OBJECTIVE
  Safety and efficacy of the "bridging therapy" (intra-arterial [IA] reperfusion rescue for nonresponder intravenous [IV] tissue plasminogen activator [tPA]-treated patients) is a matter of debate. Our aim was to compare IV and IV-IA thrombolysis using a case-control approach.
  
  
  METHODS
  Consecutive patients with proximal intracranial occlusion who received IA reperfusion procedures after unsuccessful IV tPA (lack of clinical improvement and arterial recanalization 1 hour after tPA bolus) were studied (IV-IA group). They were compared with occluded vessel, clot location, stroke severity, and time to treatment-matched 1 to 2 historical patients from our prospective IV tPA database with persistent occlusion 1 hour after IV tPA (IV-NR group). Arterial occlusion and recanalization were assessed with transcranial Doppler. Clinical evaluation was assessed by National Institutes of Health Stroke Scale at baseline, 24 hours, and at discharge. Symptomatic intracranial hemorrhage was defined according to the National Institute of Neurological Disorders and Stroke trial. Functional evaluation was determined by modified Rankin Scale, being functional independency defined by modified Rankin Scale score ≤2.
  
  
  RESULTS
  Forty-two IV-IA patients were compared with 84 matched IV-NR. Mean age was 71.5±2.9 years, 58 (46%) were women, and baseline median National Institutes of Health Stroke Scale score was 20 (interquartile range, 5). Mean time from symptoms to IV tPA was 176.9±113 minutes. On transcranial Doppler, complete recanalization was significantly higher in IV-IA than control subjects (12 hours: 45.2% versus 18.1%, P=0.002; 24 hours: 46.3% versus 25.3%, P=0.016) with nonsignificant better clinical evolution at 24 hours (40.5% versus 30.1%, P=0.169) and discharge (52.5% versus 39.5%, P=0.123). Symptomatic intracranial hemorrhage was similar (IV-IA 11.9% versus IV-NR 6%, P=0.205). Mortality at 3 months was 50% in the IV-IA group and 35.8% in the IV-NR (P=0.154). Forty percent of IV-IA patients were functionally independent at 3 months and only 14.9% IV-NR (P=0.012).
  
  
  CONCLUSIONS
  Bridging IV-IA treatment may improve recanalization and clinical outcome in nonresponder IV tPA-treated patients.
authors.affiliation: Stroke Unit, Neurology Department, Hospital Vall d'Hebron, Ps. Vall d'Hebron, 119-29, 08035-Barcelona, Spain. mrubifu@hotmail.com
authors.forename: Marta
authors.initials: M
authors.lastname: Rubiera
authors.forename: Marc
authors.initials: M
authors.lastname: Ribo
authors.forename: Jorge
authors.initials: J
authors.lastname: Pagola
authors.forename: Pilar
authors.initials: P
authors.lastname: Coscojuela
authors.forename: David
authors.initials: D
authors.lastname: Rodriguez-Luna
authors.forename: Olga
authors.initials: O
authors.lastname: Maisterra
authors.forename: Bernardo
authors.initials: B
authors.lastname: Ibarra
authors.forename: Socorro
authors.initials: S
authors.lastname: Piñeiro
authors.forename: Pilar
authors.initials: P
authors.lastname: Meler
authors.forename: Francisco J
authors.initials: FJ
authors.lastname: Romero
authors.forename: Jose
authors.initials: J
authors.lastname: Alvarez-Sabin
authors.forename: Carlos A
authors.initials: CA
authors.lastname: Molina
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D002545:Brain Ischemia / Q000000981:diagnostic imaging / Q000473:pathology / Q000628:therapy*; D016022:Case-Control Studies; D057510:Endovascular Procedures / Q000379:methods*; D005260:Female; D005343:Fibrinolytic Agents / Q000008:administration & dosage*; D006801:Humans; D008297:Male; D008875:Middle Aged; D017063:Outcome Assessment, Health Care / Q000379:methods; D020521:Stroke / Q000000981:diagnostic imaging / Q000473:pathology / Q000628:therapy*; D015912:Thrombolytic Therapy / Q000379:methods*; D010959:Tissue Plasminogen Activator / Q000008:administration & dosage*; D016896:Treatment Outcome; D014463:Ultrasonography
chemical_list: D005343:Fibrinolytic Agents; D010959:Tissue Plasminogen Activator